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Background Little evidence is available on the choice of linear staple reloads in laparoscopic sleeve gastrectomy (LSG). Previous literature recommends matching closed staple height (CSH) to tissue-thickness (TT) to avoid ischemia. Our objective was to examine feasibility and safety of “tight” hemostatic (CSH/TT <1) stapling and map the entire gastric wall TT in LSG patients. Methods Prospectively collected outcomes on 202 consecutive patients who underwent LSG with tight order of staples (Ethicon Endosurgery) in this order: pre-pylorus—black (CSH = 2.3 mm), antrum—green (CSH = 2.0 mm), antrum/body—blue (CSH = 1.5 mm), and white (CSH = 1.0 mm) on the body and fundus. Measurements of entire gastric wall TT were made on the first 100 patients’ gastric specimens with an electronic-dogmatic indicator. Results Study included 147 females and 55 males with a mean age of 41.5 ± 11.9 years and body mass index of 41.5 ± 3.8 kg/m 2 . Gastric wall measurements revealed mean CSH/TT ratio <1, decreasing from 0.7 ± 0.1 at pre-pylorus to 0.5 ± 0.1 at the fundus. There were 3.1% mechanical failures, mainly (68%) at pre-pylorus—black reloads. Post-operative bleeding occurred in 5 (2.5%) patients. There were no leaks or clinical evidence of sleeve ischemia. Stepwise regression analysis revealed that body mass index ( P  < 0.001), hypertension ( P  < 0.01), and male gender ( P  < 0.001) were associated with increased gastric TT . Conclusions Our study suggests that reloads with CSH / TT <1 in LSG including staples with CSH of 1 mm on body and fundus are safe. The results challenge the concept that tight stapling cause’s ischemia. Since tight reloads are designed to improve hemostasis, their application could have clinical benefit.

Background Ghrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG. Methods Resected stomach specimens from 20 MO patients undergoing SG were analyzed. Real-time polymerase chain reaction of ghrelin mRNA and immunohistostaining for ghrelin cells in three stomach regions (fundus, body, and pre-antral areas) were performed. Body mass index (BMI) and total plasma ghrelin levels were obtained before and 3 months postoperatively. Results Ghrelin mRNA was detected throughout the stomach, its expression decreasing from the fundus towards the antrum. The relative quantification for ghrelin mRNA expression was 0.043, 0.026, and 0.015 at the fundus, body, and pre-antral region, respectively ( P  = 0.05, fundus vs. pre-antral region). Average ghrelin cell counts declined from 60 ± 40 to 45 ± 20 and 39 ± 13 cells/high power fields in the fundus, body, and pre-antral region, respectively. Three months after surgery, total plasma ghrelin levels decreased from 1,676 ± 470 to 1,179 ± 188 pg/ml ( P  < 0.00001) and BMI dropped from 46 ± 6 to 38 ± 5 kg/m 2 ( P  < 0.00001). Conclusions Distribution and expression of ghrelin-secreting cells throughout the stomach were defined, emphasizing the importance of meticulous resection of the fundus during SG for maximal ghrelin cell removal.

Recurrent Clostridium difficile disease (CDD) is a difficult clinical problem because antibiotic therapy often does not prevent further recurrences. In a previous study, the biotherapeutic agent Saccharomyces boulardii was used in combination with standard antibiotics and was found to be effective in reducing subsequent recurrences of CDD. In an effort to further refine a standard regimen, we tested patients receiving a regimen of a standard antibiotic for 10 days and then added either S. boulardii (1 g/day for 28 days) or placebo. A significant decrease in recurrences was observed only in patients treated with high-dose vancomycin (2 g/day) and S. boulardii (16.7%), compared with those who received high-dose vancomycin and placebo (50%; P = .05). No serious adverse reactions were observed in these patients. Comparison of data from this trial with data from previous studies indicates that recurrent CDD may respond to a short course of high-dose vancomycin or to longer courses of low-dose vancomycin when either is combined with S. boulardii.

Introduction: Hospital endoscopy units must maximize efficiency to decrease patient wait times, increase patient satisfaction and increase productivity. Block times facilitate and optimize physician scheduling. Historically, block times were allocated based on procedure duration, not number of procedures. We introduce a new method of allocating block time. We assessed the number of procedures each physician performed as a percentage of the total number of procedures performed in the unit. Then, we evaluated the appropriateness of the current block allocation based on each physician's utilization. Methods: All providers performing procedures at the New York Presbyterian Queens hospital endoscopy unit were analyzed for number of procedures performed over six months (November 2017 through May 2018). Procedures were either standard procedures (endoscopy or colonoscopy) or extended procedures (endoscopic ultrasound, double balloon enteroscopy or endoscopic retrograde cholangiopancreatography). Extended procedures counted as two procedure slots and standard procedures counted as one procedure slot. Each provider was evaluated for their allocated percentage of procedure slots out of the total unit block time compared to the percentage they actually used. Results: Three categories of provider utilization emerged. Twenty providers had low utilization, using between 0.16% and 1.93% of the total unit procedure slots. Four had mid-level utilization using between 6.49% and 9.13% of the total procedure slots. Finally, two providers had high utilization using between 21% and 27% of the total procedure slots. The second part of the evaluation compared each provider's actual utilization to their allocated slots. Three providers were allocated fewer slots than they used. Fourteen providers were allocated between one and four times more slots than they used. Three providers were allocated between eight and thirteen times more slots than they used. Conclusion: We propose a new method to allocate block time. We evaluated each provider's percentage of procedures performed out of the total number of procedures and compared that to the percentage of block time they are allocated. The new method would reassign block time based on number of procedures performed. In this way, physicians would be incentivized to be more efficient by receiving more block time. This redistribution will decrease patient wait times for procedures, optimize physicians slot usage and increase overall efficiency.

Introduction Intussusception (IS) is rare in adults. However, the more frequent use of cross-sectional imaging has resulted in an increase in its detection. Because of the reported association with celiac disease, we determined the prevalence of IS among a cohort with celiac disease. Methods An anonymized prospectively maintained celiac disease database and radiological database were reviewed. Results Of a total of 880 patients, 14 (age 47 ± 17.5 years; 50% female) had IS that was detected by CT in 10, capsule endoscopy in three, and barium studies in two. The reason for evaluation was abdominal pain in 78% (11/14), whereas in the remainder (3/14) were incidental. IS was the initial manifestation of celiac disease in 57% (8/14). Two patients were found to have lead-point intussusceptions and both had small-bowel adenocarcinoma, and 10/14 had severe villous atrophy (subtotal or total). Among those with established celiac disease, IS was detected early, within 3 years of diagnosis. Follow-up was available for 11 patients, 9 of who adhered strictly to a gluten-free diet, and six had no recurrence. Among all the patients diagnosed with IS on radiologic studies at our institution, 45 were considered to have idiopathic IS. Only two of these patients had evaluation for celiac disease. Conclusion IS occurs in celiac disease. It may be the initial presentation and is associated with abdominal pain. Adenocarcinoma needs to be excluded. The majority of patients do not have recurrent symptoms after adherence to a gluten-free diet. Celiac disease should be considered more frequently when IS is encountered.

Background Video capsule endoscopy (VCE) is mainly used to evaluate patients with celiac disease in whom their course after diagnosis has been unfavorable and the diagnosis of adenocarcinoma, lymphoma or refractory celiac disease is entertained, but it has been suggested that VCE could replace esophagogastroduodenoscopy (EGD) and biopsy under certain circumstances. Methods We report a single center case series of 8 patients with suspected celiac disease who were diagnosed by VCE. Results EGD and biopsy had been performed in 4 patients resulting in a negative biopsy, declined by 2, and contraindicated in 2 due to hemophilia and von Willebrand disease. In all patients, mucosal changes of scalloping, mucosal mosaicism and reduced folds were seen in either the duodenum or jejunum on VCE. Follow-up in 7 patients demonstrated improvement in either their serological abnormalities or their presenting clinical features on a gluten-free diet. Conclusions Our case series demonstrates that VCE and the visualization of the characteristic mucosal changes of villous atrophy may replace biopsy as the mode of diagnosis when EGD is either declined or contraindicated, or when duodenal biopsies are negative and there remains a high index of suspicion. Further study is needed to clarify the role and cost of diagnosing celiac disease with VCE.

Duodenal perforation due to biliary stent migration is rare, and it often requires surgical repair; however, endoscopic closure has recently become a viable option in the appropriate patients. We present the case of a 79-year-old female who underwent biliary stent placement for a common bile duct stricture, who subsequently was found to have a duodenal wall perforation secondary to stent migration. The stent was extracted endoscopically with successful defect closure using a ConMed® repositional DuraClip™. We aim to contribute to the limited body of literature that describes endoscopic repair of duodenal perforation secondary to biliary stent migration using through-the-scope endoclips.

Introduction: Gastroesophageal (GE) varices are common manifestations of portal hypertension (PHT). Ectopic varices are less common but serious complications of PHT that can be located throughout the small and large bowel, biliary tree, peritoneum and pelvic organs. Regardless of their location, they confer a very high mortality if bleeding occurs.Case Presentation: A 35-year-old male presented with a 3-day history of melena. He had a past medical history of alcohol related cirrhosis. On examination, vitals remarkable for HR of 110, BP of 95/42. Abdominal exam remarkable for tense ascites. Digital rectal exam revealed black tarry stool. Hemoglobin was 8.1, platelets 28, total bilirubin 7, INR 1.89; MELD score was 21 and discriminant function 55.8. He underwent EGD showing grade 1 esophageal varices with no stigmata of recent bleeding and portal hypertensive gastropathy. However on duodenal examination, there were large clusters of varices in the second portion, not amenable to banding given their size. Patient then underwent colonoscopy showing melena in the terminal ileum, but no source of bleeding in the colon. Post-endoscopy, he continued to have melena, with further decreases in his hemoglobin despite transfusion and octreotide therapy. A nuclear bleeding scan located the bleeding to the duodenum. The patient underwent TIPS resulting in stabilization of his hemoglobin and no further episodes of bleeding. Discussion: Duodenal varices are uncommon, occurring in approximately 0.4% of patients with PHT. Literature suggests that duodenal varices are more common when evaluated via angiography. As duodenal varices rarely penetrate the submucosa, their incidence is likely severely underestimated by endoscopic detection. Nonetheless, when present within the small bowel, they can be a potential life-threatening cause of GI bleeding, with mortality rates reported as high as 40%. While clear guidelines exist for managing GE varices including prophylactic therapy with band ligation or nonselective beta blocker therapy, treatment of small bowel varices is not well defined. Current literature suggests that while endoscopic sclerotherapy, band ligation or surgical resection are potential treatment modalities, their success is unclear. Portocaval shunts, as our patient had, appear to be definitive therapy, but additional case series and studies are needed to better delineate a treatment algorithm.